Basic Information
| Provider Information | |||||||||
| NPI: | 1023012911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 HARRISON BLVD. | ||||||||
| Address2: | STE 4640 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874850 | ||||||||
| FaxNumber: | 8013874855 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 HARRISON BLVD. | ||||||||
| Address2: | STE 4640 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013874850 | ||||||||
| FaxNumber: | 8013874855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 037913 | GA | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207KA0200X | 8263858-1205 | UT | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 00570996C | 05 | GA | MEDICAID | 00570996F | 05 | GA | MEDICAID |